Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 994759 DEA: 120T1004 EFIS: 1222000002
QA Service Level: 1
DIST-CO-RTE-PM: 12-ORA-90,91-0.0-18.0
Work Description: Treat bridge, overlay with polyester concrete and replace joint seal.
Location Description: ROUTE 90 AT ESPERANZA ROAD OVERHEAD AND ON ROUTE 91 FROM CARMENITA ROAD PEDESTRIAN OVERCROSSING TO COAL CANYON ROAD UNDERCROSSING
Contractor Name: TRUESDELL CORPORATION OF CALIFORNIA
Contractor Address: Unknown
Resident Engineer: Nabil Ruda Structure Rep.: Unknown
DIME Sample ID: 2023-06-13-25
TL Number from the TL Form:
Sample Submitted By Organization: CT D12 - Huntington Beach Field Laboratory
Sample Organization Contact: 9492798846
Type of Sample: Quality Assurance
Type of Material: Polyester
Sample Taken Date: 06/13/2023
Date that the sample was received by the laboratory/organization performing the testing: 06/13/2023
The quantity of what the sample constitutes: 1
A brief description of the sample: polyester
From where was the sample collected: Job Site
Laboratory sample identification: 23-0188
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Collected at jobsite
